02093851-00279-0209-3851 NATIONAL RECOGNIZED TESTING LABORATORY CERTIFICATION CDRL DI-MISC-80678 REV 5-1-2019.doc
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CONTRACT DATA REQUIREMENTS LIST
Form Approved
(1 Data Item)
OMB No. 0704-0188
Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding thus burden estimate or any other aspect of this collection o f information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.
| A. CONTRACT LINE ITEM NO. |
| B. EXHIBIT |
| C. CATEGORY: |
| 0002AC |
| C |
| TDP |
TM
| OTHER MISC |
| X |
| D. SYSTEM|ITEM |
| E. CONTRACT/PR NO. |
| F. CONTRACTOR |
| 1. DATA ITEM NO. |
| 2. TITLE OF DATA ITEM |
| 3. SUBTITLE |
17. PRICE GROUP
| C001 |
| CERTIFICATION/DATA REPORT |
NATIONAL RECOGNIZED TESTING LABORATORY (NRTL) CERTIFICATION
| 4. AUTHORITY (Data Acquisition Document No.) |
| 5. CONTRACT REFERENCE |
| 6. REQUIRING OFFICE |
18. ESTIMATED TOTAL PRICE
| DI-MISC-80678 (DD) |
| PER CONTRACT |
| PURCHASING ACTIVITY |
| 7. DD 250 REQ |
| 9. DIST STATEMENT REQUIRED |
| 10. FREQUENCY |
| 12. DATE OF FIRST SUBMISSION |
| 14. DISTRIBUTION |
DD
| ONE/R |
| SEE BLOCK 16 |
b. COPIES
| 8. APP CODE |
| D |
| 11. AS OF DATE |
| 13. DATE OF SUBSEQUENT SUBMISSION |
| a. ADDRESSEE |
| DRAFT |
| FINAL |
N/A
| N/A |
| N/A |
| Reg |
| Repro |
| 16. REMARKS |
| N4523A |
| 0 |
| 1 |
| 0 |
Block 4: Tailored to allow the vendor to only provide: 10.1, 10.2, 10.2.4, 10.3, 10.3.1-Provide actual values IAW procurement specification. Ensure certs provided are traceable to material via unique markings, 10.5.
Block 9: Distribution Statement D. Distribution authorized to DoD and DoD contractors only. Administration and operations only, effective 8/20/2020. Other U.S. requests shall be referred to COMNAVSEASYSCOM.
Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow (WAWF) e-Business Suite.
Upon submission in WAWF send email notifications to: PSNS.WAWFQACertifications.FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.
Document No.: 0209-3851
| 15. Total |
| 0 |
| G. PREPARED BY |
| H. DATE |
| I. APPROVED BY |
| J. DATE |
| /s/ Derek Dunlap |
| 8/20/2020 |
| /s/ Malvin Doinog |
| 8/20/2020 |
DD FORM 1423-1, JUN 90 (EG)
| Page |
| 1 |
| of |
| 2 |
| Pages |
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